Pattern and causes of missed appointments in a Nigerian Psychiatric Hospital: A cross-sectional study

Psychiatric patients exhibit a higher rate of missed appointments compared to other medical specialities, leading to provider frustration, increased relapse, and suboptimal outcomes. This study investigates the patterns and correlates of missed appointments among outpatients at the Federal Neuropsychiatric Hospital in Calabar, Nigeria. A cross-sectional study involving 403 consecutive outpatient clinic attendees was conducted. The study questionnaire inquired about sociodemographic characteristics and hospital utilization. The Oslo Social Support Scale, the Internalized Stigma of Mental Illness Scale, the Perceived Devaluation and Discrimination Scale, and the Treatment Perception Questionnaire were administered. The mean participant age was 36.19 years (SD = 11.25), with females constituting 52.6%. Missed appointments occurred in 16.6%. The primary reasons for missed appointments included financial difficulties, forgetfulness, and distance to the hospital. Factors significantly associated with missed appointments were marital status (married), having children, believing appointments were too frequent, medication nonadherence, and concerns about medication cost (P < .05). Additionally, individuals who received unorthodox or delayed traditional care during their first mental health episode were more likely to miss appointments (P < .05). Missed appointments are prevalent among psychiatric patients, often attributed to financial challenges, forgetfulness, and geographical barriers to the hospital. Some of these factors are modifiable, suggesting targeted interventions in adherence improvement programs are needed.


Introduction
Mental, neurological, and substance use (MNS) disorders contribute about 14% to the global disease burden in high and low-income countries. [1]Despite being globally recognized as a crucial public health concern, it is less prioritized in sub-Saharan Africa, which bears more than 70% of the global mental health burden. [1]Treatment coverage remains notably insufficient in the region, with a gap often exceeding 90%. [2]n Nigeria, <10% access needed care despite the availability of effective and affordable treatments. [1,3]Human resource limitations further contribute to the deficit in treatment coverage.Compared to a global average of 9.0, the African region has 1.4 mental health workers per 100,000 people. [4]Other problems persist, such as inadequate government commitment, a lack of enabling policy or legislation, and poor financing.In addition, specialist mental health care concentrates in urban areas, limiting accessibility for most of the population. [1]Travelling long distances for treatment discourages health-seeking and treatment adherence. [5]ental disorders are typically chronic conditions requiring long-term care, and patient compliance is essential for optimal clinical outcomes. [5]Unfortunately, psychiatric patients exhibit a 2-fold higher rate of missed appointments compared to other medical specialities. [5]Patients who miss appointments benefit suboptimally from clinical supervision and are less likely to make informed decisions about their care. [5]Furthermore, poor attendance translates to higher healthcare expenses due to illness exacerbation, frequent relapses, re-hospitalization, greater risk of assault, risky behaviors, self-harm, and poorer outcomes. [6,7]Missed appointments can also negatively impact the quality of care, hindering patient-provider communication, fostering provider frustration, and weakening the therapeutic relationship. [5,6,8]Many factors hinder hospital attendance in psychiatric patients, such as financial costs, lack of transportation, inconvenient appointments, distance, and stigma, among others. [5]Elucidating these factors in research is vital for policy development and service reorganization for an improved reach.
Addressing the limited access to mental healthcare in Nigeria requires innovative solutions.Integrating psychiatric care into Primary Healthcare Centers (PHCs) holds the greatest potential for reaching most of the Nigerian population, particularly those residing in rural and suburban areas who rely solely on this tier of care. [9]The 2013 Policy on Mental Health Service Delivery in Nigeria not only advocates for this integration but also offers guidelines for successful implementation across all 3 tiers of healthcare delivery. [9]However, only 3 of Nigeria's 36 states (Osun, Ogun, and Lagos) have integrated mental health services within their PHCs. [9]his study was conducted as baseline research for developing community mental health services within Cross River State in Nigeria's South-South region.It aimed to investigate the pattern of missed appointments and establish the common reasons and correlates of missed appointments among patients attending the outpatient clinic.The anticipated outcomes of this research were to uncover barriers to accessing services in the local psychiatric hospital, potentially justifying the establishment's decision to integrate mental health care into Primary Health Centers (PHCs).This baseline data would also be utilized to advocate for the government and key stakeholders to support and fund the project.Additionally, the data generated by this research could inform local hospital policies and interventions for improving hospital attendance.Furthermore, our findings might apply to other psychiatric hospitals in Nigeria, as they serve a comparable population within a similar socioeconomic and cultural terrain.Our results could offer them valuable insights for similar interventions to integrate mental health services into PHCs or improve treatment adherence.

Study design
This was a cross-sectional study among outpatients of the Federal Neuropsychiatric Hospital, Calabar.The study strictly adhered to the guidelines for strengthening the reporting of observational studies. [10]
The Federal Neuropsychiatric Hospital is located in Calabar South Local Government Area (LGA).It currently has 200 beds and provides mental health services to Cross River State, which has a population of about 4 million.The hospital's reach extends beyond the state, catering to patients from the catchment area, including Benue, Akwa Ibom, Abia, Ebonyi, and even Cameroon.Some have to travel long distances to reach the hospital.For example, patients from Obudu LGA (located within the state) travel approximately 428 km in a 6-hour journey to access hospital services.Data were collected in the outpatient clinic of the hospital in November 2021.

Study participants
All patients attending the clinic who were over 18 years of age, registered as patients for at least 1 year, and stable enough to fill study questionnaires were considered eligible for recruitment.

Sample size calculation
The Cochran formula was employed using a known proportion [11] to estimate the sample size at 95% confidence interval (CI) and 5% precision level. [12]This resulted in a sample size of 374.To account for potential nonresponse, we increased the sample size by 10%, bringing the final sample size to 411.

Study variables
Data were collected using self-report questionnaires in the following sections.Researchers generated the list based on previous research and their experience with psychiatric patients over several years of practice.Respondents were also allowed to fill in other unlisted reasons as applicable.
A question in this section (How often do you miss your hospital appointment?)assessed the rate of missed appointments.Possible responses were on a 5-point Likert scale ranging from Very Frequently, Frequently, Occasionally, Rarely, Very Rarely, Never.In this study, "missed appointments" were operationally defined as those who missed appointments very frequently, frequently or occasionally.

Section C:
This section included the following instruments.a. MacArthur Scale of Subjective Social Status: This visual analog scale is a 10-rung ladder that measures socioeconomic status. [13]Higher rungs indicate affluence, while lower rungs reflect a low socioeconomic status.The scale does not have standardized cutoffs and was treated as a continuous variable in the analysis.It is a valid measure of social class with good psychometric properties. [14].Oslo Social Support Scale (OSS): This scale assessed respondents' social support.It is a 3-item measure that inquires about the concern shown by others, the number of people that can be reached in times of crisis and the ease of getting help from neighbors.Low scores suggest a low level of social support.The OSS is a valuable tool due to its brevity and well-established psychometric properties. [15]

c. Internalized Stigma of Mental Illness (ISMI-10) scale:
This is a 10-item measure of self-stigma, i.e. the extent to which patients stigmatize themselves. [16]It has a 5-point Likert scale ranging from strongly disagree to strongly agree, and higher scores indicate a greater level of internalized stigma.ISMI has been used in many countries and is reliable and valid. [16].Perceived Devaluation and Discrimination Scale (PDD): This instrument was used to measure the extent to which respondents believe others will discriminate against people with a mental disorder. [17]t has 12 items using a 6-point Likert scale requiring responses ranging from strongly agree to strongly disagree.A high score indicates a higher perception of discrimination evaluation, and the scale has been shown to have acceptable reliability and validity. [17,18]. Treatment Perception Questionnaire (TPQ): This self-report tool assessed patient satisfaction with services.It consists of ten items rated on a Likert scale with options ranging from strongly agree to strongly disagree.[19] It was chosen because of its brevity and has been shown to have good psychometric properties.Higher scores indicate greater satisfaction with services.[19] 2.6. Stud procedure On clinic days, respondents were approached during wait time for participation.The aims and objectives were explained, and consenting patients were consecutively recruited. Thisocedure, which included administering study questionnaires, was done by trained research assistants.Although the consecutive sampling technique was employed, bias was reduced by a strict and uniform application of inclusion and exclusion criteria and sampling over various clinic cycles, capturing a wide demographic range and reducing temporal bias.Furthermore, we employed research assistants for questionnaire administration, with researchers remaining blind to this process, adding a layer of objectivity.

Ethical consideration
The research received approval from the Ethical Research Committee of the Federal Neuropsychiatric Hospital in Calabar, Nigeria.All participants provided informed consent before their inclusion.Furthermore, this study strictly followed the Helsinki Declaration's principles regarding human subject research.

Data analysis
IBM SPSS Statistics for Windows, version 22.0 (IBM Corp; Armonk, NY, USA) was used for data analysis.Sociodemographic variables were expressed as frequencies and proportions.
Pearson chi-square test and Student t test were done for bivariate analysis.The alpha level was set at 0.05.

Results
A total of 411 questionnaires were distributed, with 8 excluded due to incomplete data, resulting in a final sample size of 403 participants.As seen in Table 1, most respondents were over 45 years of age, with a relatively equal distribution of males and females.About a third were married, and almost half had attained tertiary education.Over 50% were employed, but the overwhelming majority earned <50,000 Naira monthly.Notably, most respondents lived in the city of Calabar.
After categorization based on operational definition, 67 (16.6%) had missed appointments.Reasons why patients miss their appointments, in order of frequency, were as follows: Financial problems in 79 cases (19.6%); forgetting in 44 (10.9%), hospital distance in 33 (8.2%), school or work demands in 19 (4.7%), poor quality of service in 11 (2.7%), visits being too frequent in 10 (2.5%), attendance being an embarrassment to family in 9 (2.2%), belief that their illness is spiritually caused in 9 (2.2%), to avoid being identified as mentally ill in 8 (2.0%), due to other competing engagements in 8 (2.0%), feeling ashamed to attend in 7 (1.7%),time wastage by visits in 7 (1.7%),low-income family support in 7 (1.7%),treating self by other means in 7 (17%), and missing appointments after remission in 4 cases (1.0%).Tables 2-4 show the results of bivariate analyses to determine the correlates of missed appointments.Being married, having children, believing appointments were too often, perceiving medication as expensive, and missing medication frequently were significantly associated with missing appointments (P < .05).Interestingly, participants who initially received unorthodox care or experienced delays in receiving traditional care during their first mental health episode were also more likely to miss appointments (P < .05).Other variables such as employment status, income, residence, being accompanied by a relative, hospital trip duration, transportation cost, social support, self-stigma, perceived stigma and service satisfaction were not significantly associated with missed appointments (P < .05).

Discussion
This study investigated the patterns and factors associated with missed appointments among outpatients attending a psychiatric hospital in Nigeria.Based on our operational definition, we found that less than a fifth (16.6%) of participants missed their appointments.The primary reasons for missed appointments included forgetting, financial difficulty, and hospital distance.Variables associated with missed appointments were marital status, having children, perceptions concerning the cost and regularity of treatment, receiving unorthodox care or delayed care in the first episode of illness, and medication adherence.The measurement of missed appointments varies widely across studies, which limits direct comparison. [20]However, our prevalence falls within the reported range (8.1-46.2%) in previous research. [11,21]Despite the variation in estimates, missed appointments are generally higher among individuals with mental illness than nonpsychiatric populations and constitute a public health challenge. [5]][24] Forgetting appointments, although most common in other studies, ranked second in our findings. [11,22]Financial difficulty emerged as the top reason for missed appointments in our study, reflecting a challenge common in resource-constrained settings like Nigeria, where out-of-pocket payments are the norm. [11,22]This contrasts with studies conducted in developed nations like the USA and Taiwan, where health insurance likely mitigates financial barriers. [25,26]Additionally, consistent with prior research, hospital distance was another significant factor associated with missed appointments. [11,23]issed appointments were higher among the married, consistent with findings from an Indian study [27] ; however, most studies do not report a relationship. [22]Contrarily, some Nigerian studies found that the unmarried were more likely to miss appointments and surmised that the social support from marriage improved clinic attendance. [6,23]While this proposition appears plausible, it is essential to acknowledge that married individuals contend with additional family responsibilities, potentially impeding their ability to attend clinics consistently.Supporting this notion, we found that respondents with children also had poorer attendance.Disparities in how missed appointments are measured across studies could contribute to variations in findings.
We expected an association between missing appointments and socioeconomic status indicators such as education, employment, income, and affluence.This would have supported our finding that financial difficulty was the most common reason for missed appointments.Some previous reports found an association with socioeconomic factors, [20,23,28] but others revealed none. [22,29,30]nterestingly, our study found that patients who believed medications were expensive were more likely to miss appointments.While this suggests a potential role for socioeconomic factors, it might highlight the relative importance of perception rather than the actual cost of treatment.Social inequalities are known to affect healthcare access. [31]Our approach to measuring missing appointments, which was subjective rather than objective, might account for the non-significance.
Contrary to previous reports, other variables that strain resources, such as distance, transportation cost, and hospital trip duration, were unrelated to missing appointments. [20,23,32,33]This could again be attributed to our reliance on self-reported missed appointments.Similarly, the frequency of visits also showed statistical non-significance.However, believing hospital visits were too frequent significantly correlated with missed appointments.This finding underscores the importance of considering patient attitudes toward treatment requirements and their healthcare experience.
Consistent with previous research, our study found a link between medication nonadherence and missed appointments. [34,35]Both are treatment adherence variables, and their correlation is expected.Factors that determine hospital attendance might also affect compliance with medication.Furthermore, patients who miss their medication might be more likely to relapse, increasing the likelihood of missing appointments.
Delayed access to care at illness onset was associated with missed appointments, suggesting that barriers to the first hospital contact might impede subsequent contact as well.In this study, Bold values are statistically significant (P < 0.05).CI = confidence interval, OR = odds ratio.www.md-journal.compatients who received unorthodox care in their first episode had more missed appointments.Cultural norms and competing traditional models of care are known barriers to accessing mental health services. [36]Beliefs that mental illness has a spiritual cause or doubts about conventional care might lead to a preference for alternative treatments.While those who missed appointments expressed a greater willingness for reminders compared to regular attendees, this difference was not statistically significant.Even so, this information is clinically valuable, especially as forgetting was one of the most common reasons for missed appointments.Those who forget their appointment dates probably recognize that reminders would be helpful, which might explain their willingness.
[39] Family support reduces relapse and improves clinical outcomes. [40]Our instrument may not have captured the specific aspects of social support crucial for treatment adherence.Similarly, stigma was not linked to missed appointments, contradicting previous research on its influence on healthcareseeking behavior among those with mental illness. [41,42]This inconsistency may be due to how we measured missed appointments.Finally, patient satisfaction did not correlate with missed appointments, which also differs from some past studies. [27,37]ince the questionnaires were administered within the hospital, patients might have given more socially desirable responses concerning their service satisfaction.

Limitations
The study location, sample size, sampling technique, and study design are potential sources of bias that may impact the generalizability of the findings.Efforts were made to mitigate this by standardizing the sample size (exceeding the minimum calculation) and training research assistants to minimize recruitment bias.However, other limitations are worth noting.Using a subjective self-report measure of missed appointments could result in recall bias.
Additionally, asking patients about service utilization while they wait for care might introduce social desirability bias.Furthermore, relying on a single question to measure missed appointments might not provide a complete picture.These limitations could explain the lack of statistical association with factors like hospital distance and transportation costs.
It is important to note that a lack of statistical significance does not necessarily imply these variables have no substantive impact on clinical outcomes.Future research could benefit from adopting a more objective measure of missed appointments or using more comprehensive scales to explore reasons for poor clinic attendance.

Conclusion and recommendations
This study found that missed appointments are prevalent among psychiatric outpatients.Interventions are critically needed to address reasons for missed appointments and ultimately improve clinic attendance.Our findings suggest several strategies to enhance clinic attendance.Decentralizing psychiatric services by integrating them into primary healthcare settings could lessen the impact of distance and transportation costs, making care more accessible.Additionally, implementing a system for sending appointment reminders could help patients who forget appointments.
Furthermore, adopting a more patient-centered approach is crucial.Increased patient involvement in treatment planning, particularly regarding appointment scheduling, might address concerns about appointment frequency and improve overall treatment engagement.Prioritizing patient psychoeducation can also enhance their understanding of the treatment plan and the rationale behind appointment frequency.Finally, improved mental health advocacy and education for the general population can address socio-cultural norms and health behaviors that hinder access to conventional mental healthcare services.

Table 1
Sociodemographic and missed appointment variables.

Table 2
Sociodemographic correlates of missed appointment.

Table 3
Other correlates of missed appointment.

Table 4
Other correlates of missed appointment continued.